Company sanitized 

Does not contain Confidential Business 

Information (CBI)

Appendix C

Draft Facility Report on Emissions 
2010/15 PFOA Stewardship Program 

Draft Facility Report on Emissions

I. CHEMICAL IDENTIFICATION

Identify the chemical for which you are submitting information:

Chemical name:_Precuesors__

CAS number:________________________

II. COMPANY IDENTIFICATION

Identify the company and location of the facility submitting information:

Company name:_AGC SEIMI CHEMICAL CO.,LTD

Site location:_2276-2,Nada,Hirai,Kashima City,Ibaraki,314-0012 Japan

Identify a company technical contact who can respond to inquiries about the information 

submitted:

Technical contact:__Shunji Odaka____

Phone: _+81-467-82-4398 

Address:_3-2-10,Chigasaki,Chigasaki City,Kanagawa,253-8585 Japan
III. ON-SITE ACTIVITIES

Calendar year for which you are reporting: Jan 1, 2011 to Dec 31, 2011

(Normalized data based on year end run rate.)

Provide the amount of chemical identified above for the reporting year at specific site:

 Imported (virgin) ___0_______kgs/yr

 Imported (externally recycled) ___0_______kgs/yr

Manufactured ___CBI___kgs/yr

Estimate the amount of subject chemical distributed off-site:

___100____% of manufacture/import

Provide the amount used (including any that was manufactured, imported [virgin or externally 

recycled], or internally recycled) of the subject chemical for the reporting year at specific site: 

____0______kgs/yr

Narrative Description and Process Flow Schematic: 

Provide overall material balance of the chemical being reported, showing releases and 

products (kgs/year). Use the following page to provide a narrative description and process flow 

schematic of on-site activities, and include information that gives an understanding of the 

nature and extent of potential exposures to the subject chemical. Attach additional pages if 

desired. The narrative and process flow schematic should cover major unit operations and 

chemical conversions for manufacturing and on-site uses, if applicable. The narrative should 

provide insight into why and how releases are caused by the process. The schematic should 

show the points of release of the subject chemical in the workplace and to the environment. In 

the event the subject chemical is used in many different processes, provide information on each 

major process instead of each individual process. 
Narrative Description and Process Flow Schematic: 

 
IV. SITE RELEASE AND TRANSFER INFORMATION 

(For manufacturing and on-site processing/use if applicable)

In this section, estimate the total media-specific releases after on-site treatment of the 

chemical from your facility. You may estimate the releases by using monitoring data or any 

other method you believe appropriate. Estimates should be reported in kgs per year for the 

reporting period. Enter the values as whole numbers to no more than two significant figures. 

For example, if your annual releases are estimated to be 12,360 kgs, an estimate of 12,000 kgs 

should be reported.

Estimate the number of days per year the release occurs. Enter a whole number with a 

maximum of 2 significant figures.

Insert “NA” for release activities not associated with the chemical or “0” for releases of 

less than 0.5 kgs per year.

For all releases, the source of data and/or basis for determination should be described in 

detail. Suggested information about the possible sources/basis includes:

1. If the source/basis is an analytical measurement, then

 Describe the method (including analytical standards used, sampling, sample

treatment, analysis).

 Describe the uncertainties and assumptions made.

 Give the Level of Detection (LOD)/Level of Quantification (LOQ).

2. If the source/basis is a mass balance, then

 Show the mass balance calculation.

 Show that the mass balance closes.

 If the mass balance does not close, then report the fraction of total feedstock 

that is not accounted for and the assumptions you made to correct the balance. 

Describe the uncertainties.

3. If the source/basis is other than measurement or mass balance, then

 Describe the method used. For example, if engineering calculations are used, 

give a general description and state your assumptions. Describe the 

uncertainties.
Part IV (cont.)

A. ON-SITE AIR RELEASES

Estimate the total fugitive or non-point releases to air and the number of days per year 

the releases occur. These releases include equipment leaks from valves, pump seals, flanges, 

compressors, sampling connections, and open-ended lines; evaporative losses from surface 

impoundments and spills; releases from building ventilation systems; and, any other fugitive or 

non-point air emission.

In addition, estimate the total releases that occur through stacks, vents, pipes, or other 

confined air streams as stack or point source releases. Include storage tank emissions and 

releases from pollution control equipment.

If desired, you can provide estimates of the accuracies of your release estimates.

Estimated Total Estimated % # Days/year

Annual Releases Accuracy Release Occurs

(kgs) (Optional)

Fugitive (non-point) _0____ _____ __0___

Stack (point) _0____ _____ __0___

Basis for each release estimate:

(See discussion on source/basis in beginning of Section IV.)

Practically, all operations are conducted under closed system

Comments:

(This section is available to clarify your responses. Attach additional pages if desired.)
Part IV (cont.)

B. WATER RELEASES FROM SITE

Estimate the total releases of the chemical leaving the fence line of your facility from 

all discharge points to all streams or water bodies. Include all discharges from process outfalls 

such as pipes, open trenches, releases from on-site wastewater treatment, and contribution from 

storm water runoff, if applicable. Do not include discharges to a POTW or other off-site 

wastewater treatment facilities. If desired, you can provide an estimate of the accuracy of your 

release estimate.

Estimated Total Estimated % # Days/year

Annual Releases Accuracy Release Occurs

(kgs) (Optional)

Water releases: __0___ _____ __0__

Enter the names of the streams or water bodies to which the facility directly discharges 

the chemical. Also, enter the NPDES permit number for the facility. If more than one number 

is assigned to the facility, list each number for the appropriate discharge quantity and receiving 

water identified.

Receiving Water Name(s):____________

NPDES number(s):_______________

Basis for each release estimate:

(See discussion on source/basis in beginning of Section IV.)

Practically, no waste water (effluent) is generated.

Comments:

(This section is available to clarify your responses. Attach additional pages if desired.)
Part IV (cont.)

C. ON-SITE LAND RELEASES

Estimate the total releases of the chemical for each category of land disposal, if 

applicable. Estimate only on-site releases. Do not estimate leaks from landfills separately. This 

should be accounted for in your estimate of total landfill release.

Releases to land treatment/land amendment include all waste containing the chemical 

that is applied or incorporated into soil on-site. Do not include waste that is landfilled.

Surface impoundments are natural topographic depressions, man-made excavations, or 

diked areas formed primarily of earthen materials designed to hold an accumulation of the 

chemical.

Underground injection is the technology of placing fluids underground, in porous formations 

of rocks, through wells or other similar conveyance systems.

Other releases include any amount of the chemical that is released to land other than 

those listed. An example is the accidental release of the chemical from an underground 

pipeline or storage tank.

Estimated Total Estimated %

Annual Releases Accuracy 

(kgs) (Optional)

Landfill __0__ _____

Land Treatment/Land Amendment __0__ _____

Surface Impoundments __0__ _____

Underground Injection __0__ _____

Other (specify): __0__ _____

Basis for each release estimate:

(See discussion on source/basis in beginning of Section IV.)

Comments:

(This section is available to clarify your responses. Attach additional pages if desired.)
Part IV (cont.)

D. OFF-SITE TRANSFERS

Estimates of off-site transfers should be similar in accuracy and precision to previous 

release estimates.

Dl. Transfer to Publicly Owned Treatment Works (POTW)

Number of days/year the release occurs: __0__

Estimate the total quantity of the subject chemical, not the waste stream, transferred to 

the POTW. Complete section below for each POTW to which your facility discharges 

wastewater containing the chemical. Enter the POTW’s NPDES permit number, if known.

Annual Transfer (kgs): __0___

Estimated % Accuracy of Transfer Estimate (optional) _____

POTW Name:____________________________

Street Address: ___________________________________________

City: ________________ County: ______________

State: _____ Zip Code: _____

NPDES number: _______________________

Basis for each release estimate:

(See discussion on source/basis in beginning of Section IV.)

 Not applicable

Comments:

(This section is available to clarify your responses. Attach additional pages if desired.)
Part IV (cont.)

D2. Transfers to other off-site locations

In this section, estimate the quantity of the subject chemical, not the waste stream, 

transferred and the accuracy of the estimate for each category listed. If your facility sends the 

subject chemical in waste to an off-site location where some of the chemical will be recycled 

and the remainder will be treated, estimate each amount separately (i.e., waste treatment and 

recycling activities).

Estimated Annual Estimated %

Transfers (kgs) accuracy

(Optional)

Incineration _0_ _____

Wastewater Treatment

(Excluding POTW) __0__ _____

Underground Injection __0__ _____

Hazardous Waste (RCRA

Subtitle C) Landfill __0__ _____

Other Landfill __0__ _____

Recycle or Recovery __0__ _____

(Does not include internally recycled)

 Internally Recycled __0__ _____

Unknown or Other __0__ _____

Basis for each release estimate:

(See discussion on source/basis in beginning of Section IV.)

 

Comments:

(This section is available to clarify your responses. Attach additional pages if desired.)